Odontoid fracture following a fall in an elderly man

The patient was a 79-year-old man with a chief complaint of neck pain after a fall. Three days following the fall, the patient was seen in the emergency department, where computed tomography imaging of the head and radiographs of the cervical spine were completed. The patient was subsequently referred to a physical therapist. Due to concern for a possible undetected cervical spine fracture, the patient was immediately referred to his physician. Magnetic resonance imaging demonstrated a type II fracture of the odontoid.     

Atraumatic odontoid fractures in patients with rheumatoid arthritis.

BACKGROUND CONTEXT: Instability of the cervical spine is a common problem in patients with rheumatoid arthritis. The natural course of rheumatoid arthritis in the cervical spine is well documented. However, the true prevalence of occult fractures of the odontoid process in patients with rheumatoid arthritis is not known. PURPOSE: To draw attention to the possibility of occult, atraumatic fractures of the odontoid process in patients with rheumatoid arthritis. STUDY DESIGN: We report on two cases with previously unrecognized fractures of the odontoid process. METHODS: In this case series, we review the individual radiographic findings and clinical observations in two rheumatoid patients in whom a fracture of the odontoid process was diagnosed. RESULTS: Each one of these two rheumatoid patients had an unrecognized fracture of the odontoid process without any prior history of trauma. Their fracture was identified serendipitously during workup for neck pain. CONCLUSIONS: Occult, atraumatic fractures of the odontoid process may be found in patients with long-standing rheumatoid arthritis. This injury should be suspected if previously asymptomatic patients complain about new onset of neck pain without significant trauma.     

Fractures of the Odontoid in Children

Odontoid fractures are rare in children; they may, however, occur at any age with a prevalence in younger children. Below the age of 9, there is almost exclusively a separation of the subdental synchondrosis, whereas in children older than 9 years, the basal odontoid fracture resembles the adult type. Motor vehicle accidents (MVA) are the dominant trauma. Clinically, a substantial lesion of the upper cervical spine cannot be excluded the symptoms of odontoid fracture, such as neck pain or neck stiffness, being subtle and unspecific. Therefore, the diagnosis of odontoid fractures is based on radiographic screening of traumatized cervical spines with a standard three-view program (anteroposterior, lateral from the occiput on Th1, transoral dens view). Computed tomography (CT) and magnetic resonance imaging (MRI) are reserved to special indications. Acute odontoid fracture is mainly treated conservatively, preferably with a Minerva cast. In exceptional cases, operation with preservation of C1/C2 mobility may be indicated. The genesis of os odontoideum may be traumatic and is due to untreated odontoid fractures in children below the age of 2.5 years. Chronic atlanto-axial instability is treated by segmental fusion.     

Masking of vertebral artery dissection by severe trauma to the cervical spine

STUDY DESIGN: A prospective case study was performed. OBJECTIVES: To illustrate the association of cervical trauma with vertebral artery dissection, and to propose a diagnostic and therapeutic algorithm for suspected traumatic vertebral artery dissection. SUMMARY OF BACKGROUND DATA: Vertebral artery dissection is a recognized but underdiagnosed complication of trauma to the cervical spine. Symptoms of spinal cord injury, however, may obscure those of vertebral artery dissection, presumably causing gross underdiagnosis of this complication. METHODS: All patients with vertebral artery dissection admitted to the authors' facility between 1992 and 1997 were screened for cervical trauma. RESULTS: This article presents four patients with severe trauma to the cervical spine, defined as luxation, subluxation, or fracture, in whom symptoms of vertebral artery dissection developed after a delay ranging from several hours to weeks. The traumatic vertebral artery dissection typically was located at the site of vertebral injury or cranial to it. One patient with fracture of the odontoid process survived symptom free without ischemic brain infarctions. Another patient survived with traumatic quadriplegia in addition to large cerebellar and posterior cerebral artery infarctions. Two patients died as a result of fulminant vertebrobasilar infarctions, both with only moderate impairment from the primary spinal cord injury. CONCLUSIONS: Early signs of vertebral artery dissection include head and neck pain, often localized to the site of intimal disruption, which may be disguised by the signs of the spinal injury. Early Doppler ultrasound and duplex sonography as a noninvasive screening method should be performed for patients with severe trauma to the cervical spine. In cases of vertebral artery dissection, immediate anticoagulation should be initiated. Traumatologists should be aware of this complication in evaluating patients with severe trauma of the cervical spine, and also for a variety of forensic reasons.     

Atlantoaxial instability in a patient with neck pain and rheumatoid arthritis

Context: The purpose of this report is to describe the clinical decision-making process for a patient with rheumatoid arthritis with neck pain with underlying atlantoaxial instability.Findings: The patient was evaluated for worsening upper neck pain that began insidiously 1 year prior. The patient denied numbness or tingling in her upper or lower extremities, dizziness or lightheadedness, difficulty maintaining balance with walking, or muscle weakness. Cervical spine range of motion was limited in all planes due to pain and apprehension. The patient’s neurological examination was unremarkable. Prior flexion and extension radiographs of the cervical spine were interpreted as unremarkable with alignment preserved in flexion and extension. However, upon further inspection, the cervical spine flexion radiograph was concerning for inadequate cervical motion, which may have limited the diagnostic utility of these radiographs. Additionally, a Sharp-Purser test was performed, which was positive for excessive motion. Flexion and extension radiographs of the cervical spine were then repeated ensuring the patient adequately flexed and extended during the imaging. Severe anterior subluxation of C1 relative to C2 with cervical flexion was noted, as C1 moved as much as 8–9 mm anterior to C2 with cervical flexion. Given the degree of atlantoaxial instability, the patient subsequently underwent successful posterior fusion from the occiput to C2.Conclusion/Clinical Relevance: This case report demonstrates the importance of properly screening for upper cervical spine instability in patients with rheumatoid arthritis and neck pain and understanding the importance of obtaining adequate and appropriate diagnostic imaging.     

What defines a distracting injury in cervical spine assessment?

BACKGROUND: The National Emergency X-Radiography Utilization Study defined five criteria for obtaining cervical spine radiographic investigations in blunt trauma patients. Distracting injury was given as the indication for more than 30% of all x-ray studies ordered. The hypothesis of this study was that upper and lower torso injuries would have different effects on clinical cervical spine assessment. METHODS: This is a single-center, prospective, observational study of admitted, alert, adult blunt-trauma patients. All patients underwent cervical spine plain-film radiography. Data were collected on all injuries, physical examination findings, narcotic administration, and radiograph results. Patients with upper and lower torso injuries were compared in their ability complain of pain or midline tenderness relative to a cervical spine fracture. RESULTS: In all, 406 patients participated. All patients received narcotic analgesics before examination. Forty patients (9.9%) had cervical spine fractures, of whom seven had a nontender neck examination. All seven patients with a nontender cervical spine and a neck fracture had at least one upper torso injury. None of the 99 patients with injuries isolated to the lower torso and a nontender neck had a cervical spine fracture (p < 0.05). The frequency of cervical spine fracture among patients with cervical spine tenderness was 19.8% (n = 33). CONCLUSIONS: The National Emergency X-Radiography Utilization Study definition of a distracting injury may be narrowed. Upper torso injuries may be sufficiently painful to distract from a reliable cervical spine examination. Patients may detect spine tenderness in the presence of isolated painful lower torso injuries. Patients with spine tenderness warrant imaging.     

Flexion/extension cervical spine views in blunt cervical trauma

Objective: To examine the contribution of flexion and extension radiographs in the evaluation of ligamentous injury in awake adults with acute blunt cervical spine trauma,who show loss of cervical lord...     

Odontoid metastasis: a potential lethal complication

Nearly one third of cervical spine metastasis has a primary breast malignancy. Patients with cervical metastasis have higher mortality due to advanced stage of the malignancy. Treatment is palliative to relieve pain, prevent pathological fracture, improve mobility and function, and prolong survival. We describe a 40-year-old woman with a history of breast cancer who presented with neck and shoulder pain of 1 week duration with no neurological deficit. Following clinical examination, radiographs taken of the cervical spine was normal. Radiographs repeated 3 weeks later revealed a large lytic lesion of the odontoid occupying 70–80% of the peg. Further investigation including magnetic resonance imaging and bone scan showed no further spinal lesions. She underwent cyclical radiotherapy with complete resolution of the odontoid peg lesion and clinically was asymptomatic at 2 years. Metastatic lesions of the odontoid are atypical, and this case reinforces the necessity of early detection to evade disastrous consequences.     

The epidemiology of fractures and fracture-dislocations of the cervical spine.

A total of 717 fractures and fracture-dislocations of the cervical spine occurred in 657 patients in a 13-year period. Injury was commonest in the third decade of life. The levels most frequently injured were the second, fifth, and sixth. Injuries of the first and second cervical vertebrae commonly occurred together, and injuries involving the upper and lower cervical spine in the same individual occurred in 9 per cent of patients with fractures of C1 and C2. Odontoid fractures were the most frequent fractures in patients over 70 years of age, and formed the majority of fractures in patients over 80 years of age. It is recommended that if a fracture of the upper cervical spine is seen on radiographs, another fracture in the upper or lower cervical spine should be excluded. Patients aged 70 years and above who complain of neck pain after trauma should be suspected of having an odontoid fracture, until proven otherwise.     

Atypische dislozierte Densfraktur Typ II mit rotatorischer atlantoaxialer Luxation nach Reitunfall

We present a rare case of a combined dislocated odontoid dens fracture type II (Anderson/D’Alonzo) and rotational atlantoaxial luxation in a 15-year-old girl who was involved in a riding accident. She fell off her horse after it had stopped suddenly, losing consciousness for a few minutes. At presentation in the hospital, she had no complaints other than limited, painful neck movement. Radiologically, a posterior dislocation of an odontoid type II fracture (Anderson/D’Alonzo) was found. Computed tomography reconstruction demonstrated a rotational, hooklike fixed luxation of the left atlantoaxial facet joint. Manual repositioning after application of a cervical collar failed. Therefore, operative treatment was indicated for this highly unstable fracture. Posterior transarticular atlantoaxial screw fixation according to Magerl was performed; an iliac corticocancellous bone graft was harvested and shaped to conform to the posterior processes of C1 and C2. Additionally a hook-claw atlas fixation of C1 was done. To our knowledge, this is the first case of adolescent atlantoaxial cervical spine trauma in combination with an odontoid fracture and fixed rotational luxation reported in literature.     

Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come

BACKGROUND: Although the traditional method of diagnosing spine fractures (SF) has been plain radiography, Spiral Computed Tomography (SCT) is being used with increasing frequency. Our institution adopted SCT as the primary modality for the diagnosis of SF. The purpose of this study was to determine whether SCT scan can be used as a stand-alone diagnostic modality in the evaluation of SF. METHODS: Retrospective review of all blunt trauma patients over a two year period (1/01-12/02). Patients with neck pain, back pain, or spine tenderness underwent SCT of the symptomatic region. Patients who were unconscious or intoxicated underwent screening SCT of the entire spine. SCT was performed using 5 mm axial cuts with three-dimensional reconstructions in sagittal and coronal planes. Patients with a discharge diagnosis of cervical, thoracic, or lumbar SF were identified from the trauma registry by ICD-9 codes. RESULTS: There were 3,537 blunt trauma patients evaluated, with 236 (7%) sustaining a cervical, thoracic, or lumbar SF. Forty-five patients (19%) sustained a SF in more than one anatomic region. SCT missed SF in two patients. The cervical SF missed by SCT was a compression fracture identified by magnetic resonance imaging and was treated with a rigid collar. The thoracic SF missed by SCT was also a compression fracture identified on plain radiographs and required no treatment. CONCLUSIONS: SCT of the spine identified 99.3% of all fractures of the cervical, thoracic, and lumbar spine, and those missed by SCT required minimal or no treatment. SCT is a sensitive diagnostic test for the identification of SF. Routine plain radiographs of the spine are not necessary in the evaluation of blunt trauma patients.     

Impact of intravenous acetaminophen therapy on the necessity of cervical spine imaging in patients with cervical spine trauma

Objective：We evaluated a new hypothesis of acetaminophen therapy to reduce the necessity of imaging in patients with probable traumatic cervical spine injury.Methods：Patients with acute blunt trauma to the neck and just posterior midline cervical tenderness received acetaminophen （15 mg/kg） intravenously after cervical spine immobilization.Then,all the patients underwent plain radiography and computerized tomography of the cervical spine.The outcome measure was the presence of traumatic cervical spine injury.Sixty minutes after acetaminophen infusion,posterior midline cervical tendemess was reassessed.Results：Of 1 309 patients,41 had traumatic cervical spine injuries based on imaging.Sixty minutes after infusion,posterior midline cervical tenderness was eliminated in 1 041 patients,none of whom had abnormal imaging.Conclusion：Patients with cervical spine trauma do not need imaging if posterior midline cervical tendemess is eliminated after acetaminophen infusion.This analgesia could be considered as a diagnostic and therapeutic intervention.     

Management of whiplash-associated disorder addressing thoracic and cervical spine impairments: a case report

STUDY DESIGN: Clinical case report. OBJECTIVES: To describe a physical therapy program addressing impairments of the upper thoracic and cervical spine region for an individual with a whiplash-associated disorder. BACKGROUND: A 32-year-old female with complaint of diffuse posterior cervical and upper thoracic region pain was evaluated 2 weeks following a motor vehicle accident. The patient reported that she was unable to sit for longer than 10 minutes or perform household duties for longer than 1 hour. In addition, she was unable to perform her tasks as a postal worker or participate in her customary running and aerobic exercise activities because of pain in the cervical and upper thoracic region. METHODS AND MEASURES: An examination for physical impairments was performed, including the measurement of cervical range of motion using the CROM device, and the assessment of soft tissue and segmental mobility of the upper thoracic and cervical spine regions. The Northwick Park Neck Pain Questionnaire was used to assess functional limitations and disability. Manual therapy and therapeutic exercises were applied to address the identified impairments. Manual therapy techniques included soft tissue mobilization, joint mobilization, and joint manipulation. RESULTS: The patient's cervical range of motion was improved and the disability score improved from 25% to 19.5% 3 days after the initial session addressing the thoracic spine. Following a second session also addressing thoracic spine impairments and the use of therapeutic exercises for 7 days, the disability score improved to 11.1%. At the final visit 17 days following the third visit, which focused on addressing the cervical spine impairments, there was complete resolution of signs and symptoms and disability. CONCLUSIONS: Interventions addressing the impairments of the upper thoracic and cervical spine region were associated with reducing pain, increasing cervical range of motion, and facilitating return to work and physical activities in a patient with a whiplash-associated disorder. There is a need for continued research investigating the efficacy of providing interventions to the thoracic spine for patients with whiplash-related injuries.     

Imaging diagnosis of cervical spine and spinal cord injuries in children

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寰枢椎不稳定合并下段颈椎管狭窄的一期手术治疗

针对齿状突陈旧性骨折引起的寰枢椎不稳定合并Ｃ４～Ｃ６椎管狭窄，出现相应神经症状的患者，设计了Ｇａｌｉｅ法固定融合寰枢椎并同时作Ｃ３～Ｃ７右侧椎板切除，椎管潜行减压的一期手术方法，以重建寰枢椎的稳定性并缓解神经症状。该方法有缩短治疗时间，减少治疗费用，减轻患者的痛苦，以及相对安全等特点。讨论了寰枢椎不稳定合并下段颈椎管狭窄手术方法的选择，上、下颈椎同时手术时增加手术安全性的措施等问题     

Relationship between Northwick Park neck pain questionnaire and cervical spine MR imaging findings

The study was aimed at determining the association between the self-report of pain and disability by means of Northwick neck pain questionnaire (NPQ) and cervical spine MR imaging findings. A random sample of 251 patients, 132 men and 119 women aged 43±13 years, submitted with neck pain were investigated. Patients with previous discitis, surgery, neoplasm or hospitalized for cervical spine trauma were excluded. All patients completed the NPQ and were studied with sagittal gradient-echo T1 and turbo spin-echo T2, axial gradient-echo T2* and heavily T2 weighted MR myelographic weighted images. MR images of the two most affected disc levels were read, offering an MR imaging score from 0 to 30. There was no statistically significant correlation between NPQ and MR imaging scores. From the NPQ items, only difficulty in sleeping and numbness were related to the MR imaging score. Disc extrusion was the only MR finding almost significantly associated with NPQ (P=0.054). Neck injury did not increase NPQ scores. In patients with neck pain, NPQ scores do not correlate with MR imaging findings. NPQ and cervical spine MR imaging show different facets of the multidimensional complex of neck pain.     

Vertebral artery injury and severely displaced odontoid fracture: the case for early reduction

Purpose

To report a novel treatment method for vertebral artery occlusion. Vertebral artery injuries have a high association with specific cervical fractures including atlanto-axial fractures, displaced fracture patterns, and transverse foramen fractures. Optimal medical management of the occluded vertebral artery has yet to be determined; however, there is an extremely high complication rate with systemic anticoagulation in these patients. Furthermore, unlike appendicular skeleton fracture-dislocations with vascular injury, there is no clear consensus as to the optimal acute management of the displaced odontoid fracture with or without vertebral artery injury.

Methods

We report on a severely displaced odontoid fracture that was found to have a vertebral artery injury. Medical records and imaging were reviewed.

Results

An 82-year-old female presented to our hospital with a type IIb odontoid fracture after sustaining a ground-level fall. Pertinent physical exam findings were ecchymosis on the left side of her forehead and posterior cervical pain without neurologic deficits. An MRA showed an occluded left vertebral artery. The patient was placed in early cervical traction and the fracture was reduced within 12 h of presentation. Following surgical stabilization, an MR angiogram showed complete reperfusion of the vertebral artery without intimal tear.

Conclusion

To our knowledge, this is the first report of a displaced odontoid fracture in which cervical traction was used to restore the perfusion of the vertebral artery. Cervical traction may obviate the need for systemic anticoagulation and should be considered in patients who have an identifiable compression of the vertebral artery even if neurologically intact.     

Subchondral cysts of the atlantoaxial joint: a risk factor for odontoid fractures in the elderly

Background contextScholars have postulated that cervical degeneration can predispose the upper cervical spine to injury after minor trauma. Subchondral cysts have previously been recognized as potentiators of fracture in the hip and knee but no cases of cervical degenerative cysts contributing to fracture have been reported.PurposeThis report documents a case series in which patients sustained significant injury to the upper cervical spine in the setting of subchondral cervical cysts.Study design/settingCase series/academic level I trauma center.MethodsBetween 2004 and 2008, six patients (ages 73–91 years) with cervical pathology were admitted to the trauma service at our Level I trauma center. The most common mechanism of injury was a low velocity fall, which occurred in 5 out of 6 patients. All patients suffered an odontoid fracture. In all cases, there was radiographic evidence of cyst formation, and computed tomographic imaging demonstrated fracture communication with the subchondral cyst.ResultsOf the six cases, four were treated definitively with immobilization in a cervical orthosis and two required surgery. One patient was treated with an occipital-cervical fusion, whereas the other underwent Brooks wiring. All patients ultimately went on to heal their fractures.ConclusionsDegenerative changes in the cervical spine have previously been recognized to potentiate injury. This report raises the question of whether degenerative processes at the C1–C2 articulation predispose elderly patients to injury at this level. The presence of cystic degeneration at the atlantoaxial joint should be recognized as a potential risk factor for cervical injury after relatively minor trauma.     

Transient headache related to enlargement of the contralateral vertebral artery after vertebral artery occlusion

BACKGROUND: Magnetic resonance imaging has the diagnostic advantages of being noninvasive and able to visualize soft tissue. However, conventional recumbent MRI may underestimate a disease because the position of imaging takes stress off the spine. CASE DESCRIPTION: A 37-year-old woman presented with complaints of pain in the neck that radiated down her right arm when she turned her head to the right and increased with extension. She complained of paresthesias, numbness/tingling in the index and middle fingers and thumb, in the C6 and C7 nerve root dermatomes. Conventional conservative measures, including anti-inflammatories, muscle relaxants, opiates, and physical therapy, had been tried without positive results. Magnetic resonance imaging was performed in a weight-bearing upright neutral position, in the extended upright position, and in the extended upright position with the head turned to the right. The latter images showed a clear protrusion at C5-C6 and C6-C7. These protrusions were not clearly evident in the upright neutral position. A targeted epidural block at C5-C6 and C6-C7 relieved the patient's pain, and she has been able to continue work. CONCLUSIONS: Magnetic resonance imaging of the cervical spine in the position that causes the patient's symptoms may increase the sensitivity and accuracy of the diagnostic study and thus provide the spine-care professional with a potentially more accurate diagnosis and a targeted treatment plan. Such MRIs may also decrease the need for myelography.     

Physical and Psychosocial Factors Associated with Neck Pain after Major Accidental Trauma

Neck pain after physical trauma is common; but previous research regarding the role of psychological and physical predictors for neck pain is inconsistent. A retrospective survey of consecutive patients presenting to a metropolitan trauma centre with major accidental trauma was performed between 1 and 6 years post injury. Possible predictor variables (demographic, injury severity, and psychosocial factors) were determined from the hospital trauma registry and the questionnaire. The main outcome was a combined score of neck pain severity and functional limitation. Multivariate logistic regression was performed to develop a predictive model for neck pain. A multivariate analysis of 355 patients showed that neck pain was not significantly associated with measures of injury severity. Neck pain was significantly more likely to be severe in patients with a cervical spine fracture, with pre-existing chronic illnesses, those with post-traumatic stress disorder (PTSD) at the time of follow up, those who had retained the services of a lawyer regarding the injury, and those with lower education levels. Psychosocial factors are important predictors of neck pain after major physical trauma. These findings do not support models for post-traumatic neck pain that are restricted to physical factors. No support was received related to this study.